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Oregon Naturopaths v. Evidence-Based Medicine

Like every state, Oregon is struggling with the unsustainable costs of taxpayer-funded health care programs. In an attempt to tame this beast, Oregon recently established a system of coordinated care organizations, or CCOs, to (as the name suggests) coordinate medical, mental health, and dental care for residents enrolled in Oregon Health Plan, the state’s Medicaid program. The new system requires supervision of this coordinated effort by the participant’s primary care physician (PCP). Not one of the 15 newly-minted CCOs has credentialed a naturopath as a PCP even though naturopaths are licensed as such by the state. Needless to say, the naturopaths are not pleased by this development.

The big stumbling block appears to be the state’s requirement that CCOs practice evidence-based medicine as a cost control measure. Unfortunately for naturopaths, evidence-based medicine is not their strong suit. Apparently scientific plausibility is not much of a concern either.

As one chief medical officer of a CCO explained in a news report,

We have an obligation to the state and to the community that the providers on our panel will deliver the evidence-based care required by the Oregon Health Plan. . . . We need to make sure that all of the providers who are empanelled meet those basic standards of care.

He has good reason for concern.  Here’s David Gorski’s apt  summary of naturopathic practice:

a hodge-podge of mostly unscientific treatment modalities based on vitalism and other prescientific notions of disease. As a result, typical naturopaths are more than happy in essence to ‘pick one from column A and one from column B’ when it comes to pseudoscience, mixing and matching treatments including traditional Chinese medicine, homeopathy, herbalism, Ayurvedic medicine, applied kinesiology, anthroposophical medicine, reflexology, craniosacral therapy, Bowen Technique, and pretty much any other form of unscientific or prescientific medicine that you can imagine.

(This post collects references to  several other SBM posts on naturopathy, including Kimball Atwood’s excellent four-part series, and here’s another one too.)

The executive director of the Oregon Association of Naturopathic Physicians (OANP) dismissed evidence-based medicine as a “red herring” although she didn’t say what she thought the real reason was or what motive the CCOs might have to obfuscate things. After all, if naturopaths could actually deliver good primary care at a cost equal to or less than M.D. or D.O. PCPs, you’d think the CCOs would jump at the chance to include them.

Fighting the “red herring”

Undeterred by this “red herring,” naturopaths have engaged in a media campaign to fight their exclusion. Unfortunately for them, the resulting media coverage simply serves to shore up the CCOs’ case against them. (You can access news reports here: Bloomberg BNA, The Lund Report Sept. 19 & Oct. 30, Portland Business Journal, The Oregonian.)

Of course, there is nothing like the touching anecdote to demonstrate how the heartless state of Oregon is going to wrest Medicaid patients from the loving arms of their naturopaths and onto the cold examining tables of M.D.s and D.O.s. But you have to question whether these examples really did the naturopaths any good. Consider these media accounts of naturopathic patients who want to keep their naturopath as their PCP:

  • Naturopath gives disabled boy a single homeopathic dose of arsenic for constipation and mom says “he pooped every single day for a year after that.”
  • Infant diagnosed with posterior urethral valve; doctors tell mom that he will most likely need kidney transplant before age 18. Naturopath tracked progress and, according to mom, they could see “it head bit by bit to more normal.” Naturopath used “various non-toxic boosters of kidney function, including homeopathic and herbal medicines.” Now almost two years old, boy is described by mom as healthy.
  • Naturopath specializing in pain management says he can “promote healing” of Crohn’s and colitis and is “able to get people’s pain managed so that they can start de-toxing.”
  • Patient who suffered stroke 10 years ago says her “nerves seem to be regenerating and she’s walking better.” Attributes this to acupuncture treatments provided by her naturopath.

In fact, in all the media reports there was only one reference to any evidence at all: “13 studies in a ‘Systematic Review of Outcome Studies of Whole Practice Naturopathic Medicine, presented at the International Research Congress on Integrated Medicine and Health.” This turns out to be a poster presentation from the conference whose purpose was stated thusly:

Individualized combinations of therapeutic modalities and remedies are generally the rule in naturopathic practice with selection determined by the system’s principles and guidelines. With the wide variation in real-world use, evaluating the whole practice best assesses the overall benefits and risks.

Note how this description fits perfectly with Dr. Gorski’s take on naturopathic practice.  The authors continued:

We have so far identified 12 [not 13] studies fitting inclusion criteria with a variety of designs in anxiety, tendinitis, temporomandibular joint disorder, low back pain, general pain, hypertension, multiple sclerosis, menopausal symptoms, cardiovascular risk and type 2 diabetes. Six were randomized trials including 2 with cost components, one a comparative prospective observational study, one a prospective single group observation, and four were retrospective. All showed some evidence of effectiveness though most had methodological weaknesses. No studies in acute disease meeting criteria were found.

And they concluded:

The review provides evidence of effectiveness and cost savings that merit further investigation of naturopathic care for chronic disease.

Thus, the most favorable evidence mustered is weak on 10 chronic conditions and non-existent on acute diseases.  It doesn’t appear that a concern for evidence-based medicine is a “red herring” after all.

(A digression: The International Research Congress on Integrative Medicine and Health was held in Portland, OR, this year, and sponsored by, among others, the Consortium for Academic Health Centers for Integrative Medicine and your tax dollars, in the form of the National Center for Complementary and Alternative Medicine. A brief perusal of the oral and poster presentations, conveniently available on-line from Bio-Med Central, is enlightening regarding the exciting research taking place in the world of integrative medicine. In addition to the poster presentation on naturopathy mentioned, a brief sampling includes: “Development of the phlegm syndrome questionnaire: a new instruction to assess traditional Chinese medicine syndrome for angina,” “Current practice among acupuncturists treating threatened miscarriage in Australia and New Zealand,” and “Does practicing Reiki alter the electromagnetic field of heart and hands of practitioners?” There is much, much more on-line and those of you with a few minutes to spare won’t be disappointed if you take a look.)

Argument and rebuttal

So if evidence-based practice, and even scientific plausibility, is out the window, why should the CCOs allow naturopaths to participate as PCPs? Here’s what they argue, taken from both media accounts and a white paper prepared by the OANP, along with my comments in italics:

There is a shortage of PCPs.

Substandard care is not the solution to the PCP shortage.

Patients have a right to choose among health care providers.

The state has an obligation to get the best care for the lowest cost when the taxpayers pick up the tab. There is no “right” to choose health care that does not fit within those parameters.

Naturopaths are licensed by the state as PCPs.

Again, the state has an obligation to taxpayers to get the most bang for the buck with public funds. Who the state legislature decides to license is of no relevance to this issue. The law does not require CCOs to accept “any willing provider.”

Oregon law says the CCOs can’t discriminate against any licensed health care provider.

A decision that exclusion equals discrimination would be in direct conflict with the law’s requirement that CCOs practice evidence-based medicine. Failure to follow evidence-based guidelines and use of modalities, such as homeopathy, which don’t even have a plausible basis in science and certainly no evidence of effectiveness, is a rational basis for the decision to exclude naturopaths. As is their inferior education and training when compared to M.D. and D.O. PCPs.

A special naturopathic vaccination plan

The OANP’s white paper deserves special comment. Noting that the naturopathic position on immunization is apparently a concern, it offers this less than reassuring statement:

[B]ecause naturopathic care is by definition patient-centered, many NDs will customize the vaccination schedule to address the patient’s risk factors, environment, and personal beliefs.

I guess being “patient-centered” includes skipping the U.S. Centers for Disease Control’s recommended vaccination schedule. They even claim this approach can actually increase vaccination rates in patients who would otherwise refuse vaccinations. Either this is a new, untried strategy or it’s not working, as these studies would indicate:

Pediatrics (2006): Found negative influence of naturopaths on mothers’ decision to vaccinate children.

Canadian Journal of Public Health (2010): Consultation with a naturopath significantly decreased the likelihood of receiving a flu shot among women in contact with young children.

Maternal and Child Health Journal (2010): Children in Washington State were significantly less likely to receive each of the four recommended vaccinations if they saw a naturopathic physician. Children aged 1–17 years were significantly more likely to be diagnosed with a vaccine-preventable disease if they received naturopathic care. Pediatric use of complementary/alternative medicine in Washington State was significantly associated with reduced adherence to recommended pediatric vaccination schedules and with acquisition of vaccine-preventable disease. (Similar results for chiropractors.)

I’ll just add that famous CAM line, “further studies are needed,” and suggest that until the evidence demonstrates otherwise, naturopaths should be viewed with a healthy suspicion when it comes to advising patients about vaccinations.

The government caves, once again

Of course, when all else fails, it’s time to turn to friends in state government for special treatment. After all, having gotten licensed in the first place via the magic of legislative alchemy, CAM providers are not shy about returning to the well for more goodies. Although the state mandated that CCOs base medical treatment on evidence, Oregon has now turned around and decided to give naturopaths a 90-day reprieve by requiring that CCOs pay for naturopathic treatment during this time period. If the CCOs exclude naturopaths after 90 days, apparently Oregon Health Plan participants will be able to see a naturopath anyway, outside of the managed care system. Paid for by the taxpayers, of course.

This is but another deplorable attempt by CAM providers to circumvent health care reform. The venue may be smaller but the tactics are the same. Under the mantle of state licensing legislation, which allows a scope of practice at odds with their actual education and training (not to mention basic science), CAM providers argue that they actually have the skills the state legislature has gifted to them. With the help of “anti-discrimination” provisions inserted into health care reform legislation by sympathizers, they then hold the threat of litigation over the heads of health care organizations trying to toe the line on costs. These tactics are simply a variation on a familiar theme, that of forcing health insurers to cover their services via another legislative favor, health insurance mandates and “any willing provider” laws. Until the state legislatures and federal government are willing to stop this nonsense, the public’s health will remain at the mercy of the fanciful remedies concocted by CAM providers and funded by us all.

Posted in: Legal, Naturopathy, Politics and Regulation, Vaccines

Leave a Comment (35) ↓

35 thoughts on “Oregon Naturopaths v. Evidence-Based Medicine

  1. windriven says:

    @Jann Bellamy

    ” Unfortunately for them, the resulting media coverage simply serves to shore up the CCOs’ case against them.”

    I didn’t read anything in the linked articles that was anything but sympathetic to the quacks.

    In the Bloomberg piece, Judy Mohr Peterson, Oregon Medicaid Director, is quoted as saying, “If there is a community desire to have those alternative providers available, we are going to encourage the CCOs to respond to that in a positive way. If we find that the CCOs are discriminating on the basis of the license, we do have the authority to take action on that basis.”

    In fact the Lund piece is the only one of the four that even mentions evidence based medicine but only in passing and only to set up a meatball for the quack spokeswoman to hit out of the ballpark.

    How could these four articles be characterized as anything but sympathetic to quackery?

    Politics is more about “the touching anecdote” than it is about science. The quack lobby will fight tooth and nail. The medical establishment, not necessarily in thrall to EBM itself, not so much, and tearful mommies extolling the virtues of this or that particular shaman will seal the deal.

    In Oregon it will be Quackery 2, EBM 0.

  2. daijiyobu says:

    According to the AANP, 11 states will introduce an ND licensure effort in January 2013:

    (see http://www.naturopathic.org/article_content.asp?edition=101&section=156&article=775 ).

    The AANP has a “State Legislative Toolbox” at naturopathic.org but it’s not publically available,

    so I don’t know their claims / labels / deceptions.

    Perhaps it’s like the one I’m familiar with from the mid 1990s, their “Scientific Basis for Naturopathic Practice”

    (see http://web.archive.org/web/19991006052144/http://www.allianceworkbook.com/history/history2.htm ), where we’re told:

    “naturopathic medicine rests on a scientific foundation [...] diagnosis using the same science [...] all thoroughly supported by science [...] each of the major therapies used by naturopathic physicians is rooted in scientific literature.”

    And licensed falsehood marches on.

    -r.c.

  3. DugganSC says:

    @windriven:
    I think the argument is that the articles in question represent very little but anecdotal accounts, i.e. the Naturopaths know that the patients are healed because the patients say so, not because there’s any evidence of healing (the constipated child having daily bowel movements aside). But yeah, for the target audience, it comes off rather positive.

  4. Janet says:

    I used to live in Portland (Portland being the main population base controls the vote–not to say that there are not plenty of rural woo lovers) and it is the poster child for a well-educated but scientifically illiterate population. Most of them would laugh at religion, even while they worship at the altar of acupuncture. “Spirituality” rules.

    Legislators, being drawn from the general population, are not likely to suddenly act in favor of reason. The real doctors (Crislip anyone?) are going to have to get together and be very vocal on this. The Mayor did stand up for fluoridation recently, so there may be some hope.

    I hate to say this, but if the majority of taxpayers in Oregon are stupid enough to spend their money on woo, perhaps that is their right? There has to be something wrong with that statement.

  5. Jann Bellamy says:

    @windriven

    “I didn’t read anything in the linked articles that was anything but sympathetic to the quacks.”

    I agree, way too sympathetic. You’d think the reporters could pick up the phone and get another viewpoint, but of course that would involve more work than simply reprinting the naturopaths’ talking points. DugganSC is correct. My intent was to show that the anecdotes support the CCOs’ claim that naturopaths do not practice EBM.

  6. Snyderwagon says:

    This blog is awesome, so glad I found it. YAY SCIENCE!

    I wish these articles were in widely-read newspapers. Oh, how the third estate has crumbled.

  7. windriven says:

    @Moebius

    This from your link sent me to the liquor cabinet:

    “We have the knowledge and techniques of a medical doctor, but we are experts in the non-drug ways of treating and preventing disease.”

    The woman is delusional. The knowledge of a medical doctor? The techniques of a medical doctor? Non-drug ways of treating disease? Does that mean a naturoquack is one’s best choice for appendectomy?

    Sometimes I think there is just no hope.

  8. DevoutCatalyst says:

    “Does that mean a naturoquack is one’s best choice for appendectomy?”

    Oh hell yeah! Dr. Norman W. Walker, DSc advocated colonics for appendicitis in lieu of appendectomy, lest you end up with a colostomy bag too from some sadistic surgeon who couldn’t help himself once he got started. I kid you not, Doc Walker’s books are insightful reading, laughter being claimed as best medicine.

    So they botch your journey with appendicitis, what would it matter, Windriven? “Even if we can’t cure, we can still heal”. Get it?

  9. zelig says:

    I have lived in Portland for 8 years and I would be absolutely shocked if the state didn’t accommodate woo with its health policies. You can’t walk 10 feet without coming across an alternative health clinic, while there is great suspicion about vaccines and fluoridation. My wife and I just had our first child and we’re being extra careful about ensuring our daughter gets vaccinated on schedule as we know so many people here go without them. I write this as a self-identified liberal, but left wing libertarianism is so much a part of the culture here that there is a general distrust of establishment institutions and exultation of anything counter culture that a lot of nonsense flies around here.

  10. agitato says:

    @windriven @Moebius

    There is no hope. I’ve just spent some time exploring the website of the Association of Accredited Naturopathic Medical Colleges. How are they allowed to use the word ‘medical’? And how can some of them call themselves “accredited universities?”

    http://www.aanmc.org/

    @windriven: If you visit the site, stay close to the liquor cabinet.

  11. gears says:

    @agitato

    I stumbled onto that website yesterday and had the exact same experience that Mark Crislip describes in his post today, where I was wondering what sort of alternate reality I had stumbled into.

    Some choice quotes:

    Naturopathic medicine students learn to treat all aspects of family health and wellness, from pediatrics to geriatrics. They attend four-year graduate-level programs at accredited institutions, where they are educated in the same biomedical sciences as allopathic physicians.

    and more horrifying:

    When comparing the training and philosophies of NDs and MDs, it’s important to remember that there is no right or wrong: each field is unique and offers distinct benefits to patients and the medical field as a whole.

    Medicine can be seen as analogous to a tree. There are many different branches of medicine, each branch possessing its own tools and methodologies. But just as branches belong to a single tree and share common roots, so too are all medical fields based on the same founding principle: the protection and improvement of the patient’s health. NDs and MDs represent two distinct branches of the medical tree, each sharing the same foundation, or “trunk.” So if you want to become a health care practitioner, understanding the similarities and the differences between the two branches of medicine is essential to determining which branch may suit you best.

    The most frightening parts are in the page about Comparing ND and MD Curricula

    What I just cannot comprehend is how people can study the “biomedical sciences” and advocate homeopathy and energy medicine (patent nonsense), or alkaline water (when they should have learned that the blood is buffered), or any of the alternative therapies that have no basis in reality.

    Postmodernism is the worst.

  12. @gears:

    Postmodernism is the worst.

    Err … No. Postmodernity, maybe, free-market economics, most definitely, but not postmodernism. Or at least, not all of it. I don’t see Derrida advocating homeopathy.

  13. Narad says:

    I don’t see Derrida advocating homeopathy.

    They’re working up to it.

  14. @Narad: I don’t misquoting Heidegger in the first paragraph counts as postmodernism. This article gave me a headache with the second paragraph.

  15. Narad says:

    I don’t [think] misquoting Heidegger in the first paragraph counts as postmodernism.

    That’s why I said “working up to it.” Still, there’s plenty of petit récit floating around here. All they have to do next is deconstruct the imposed metanarrative of the Organon.

  16. Toiletman says:

    Yes, post-modernism does through giving quacks philosophical backing in their rejection of an objective, empirical truth. Postmodernism promotes the belief that science is just another belief-system. It’s something I’ve “learned” (= I did not really learn it but it was said by professors in social “science” classes quite often) at university. Trying to rid social sciences of pseudoscientific crap is a huge pile of work but fortunately, students nowadays in our technology loving world seem to be more skeptical than ever since the stuff really started to become popular in the 60s.

  17. @Toiletman: Seriously? I mean, sure, there are a lot of quacks in philosophy, English, Comp Lit, sociology departments. But how many students go to graduate school in those subjects? How many espouse even postmodernism and which one? The vast majority of philosophy departments in the US tend to align themselves more with the Anglo-American analytical tradition. As for the rest, you don’t really have that many public intellectuals in the US. Postmodernism (which in itself is not a thing, it’s just an umbrella term for philosophical currents not aligned with the analytical tradition), though popular in humanities graduate schools, as such does not have much traction in the public discourse.

    When it comes to the rise of quackery in the public discourse, there are more probable causes than postmodernism. The degradation of public education in the sciences is one.

  18. Narad says:

    Postmodernism promotes the belief that science is just another belief-system.

    It would be hard to argue that Postmodernism really “promotes” anything, being largely impenetrable to most people. Being able to find antiscience strains of thought in one place doesn’t necessarily explain similar sentiments in another place.

  19. Quill says:

    All they have to do next is deconstruct the imposed metanarrative of the Organon.

    Ah, deconstruction. I really hate the fact that Nietzsche made such an art out of the physical metaphor and that so many like Derrida make a fat living off of it all. “Deconstruct” indeed. To paraphrase St. Mark (Twain), every time I read about deconstruction of ideas, I want to dig up Nietzsche and beat him over the skull with his own shin-bone.

    As for the rest, you don’t really have that many public intellectuals in the US.

    I think public intellectuals were made illegal some years ago, with, alas, George Will being grandfathered in under some clause having to do with his eye glasses.

  20. mousethatroared says:

    @Quill – you crack me up. Thanks for the morning chuckle.

  21. gears says:

    I guess that was a poor choice of phrase. All I meant was that it was unfortunate that naturopaths were representing naturopathy and conventional medicine as two different but equally valid approaches to medicine.

    Sorry for derailing the thread.

  22. agitato says:

    @ gears

    ‘Unfortunate’ is too kind a word. How about OUTRAGEOUS? And how is it even legal?

    This is from Bastyr University’s website:

    ‘Named by The Princeton Review as one of the 168 best medical schools in the country, the School of Naturopathic Medicine at Bastyr University is committed to developing leaders in the evolving field of natural medicine.’

    One of the 168 best medical schools in the country. Help.

  23. @agitato: That’s interesting. I have just checked Bastyr University’s page on the Princeton Review (http://www.princetonreview.com/schools/medical/MedAcademics.aspx?iid=1037876), and there is nothing about it being “one of the best 168 best medical schools in the country.” For that matter, there are no rankings provided for this school. Not that the Princeton Review is a reliable indicator for quality of education. Their ranking methodology is based on a survey of a school’s reputation and this reputation alone.

  24. Narad says:

    there is nothing about it being “one of the best 168 best medical schools in the country.”

    They’re in the 2012 edition. I couldn’t whomp up the strength to go looking at others.

  25. Jann Bellamy says:

    @ agitato, et al.

    I looked at the Princeton Review website and don’t find it ranks medical schools at all.

  26. Jann Bellamy says:

    @ agitato:

    One more thing: do you have a link to the Princeton Review ranking claim on Bastyr’s website?

  27. gears says:

    @Jann Bellamy

    The ranking claim is available here.

    @agitato

    Yes, outrageous is a more appropriate word. When reading SBM, frequently I find myself asking, “What can we do about this madness?” or wondering “Where is the lobby for SBM?”

  28. agitato says:

    @gears

    Thank you! I was just about to reply to @ Jann Bellamy with the same information.

    @Jann Bellamy

    There is no link from the claim made on Bastyr’s site to the Princeton Review.

  29. Scott says:

    When reading SBM, frequently I find myself asking, “What can we do about this madness?” or wondering “Where is the lobby for SBM?”

    Likewise. And I can’t help thinking that “us” is the answer to the latter. If we want more done than reading and tsk’ing, well, who else do we expect to do it?

    Naturally, there are always reasons not to. (An 8-month-old in the house, for example.) Not an easy thing. But that’s the bottom line principle.

  30. daijiyobu says:

    Here’s a place to start regarding Princeton Review:

    @ Princeton Review
    http://www.princetonreview.com/GradPrograms.aspx?gpid=98&page=1

    @ Bastyr
    do this search with google.com, “site:bastyr.edu princeton review”
    without the quotes.

    -r.c.

  31. Narad says:

    I looked at the Princeton Review website and don’t find it ranks medical schools at all.

    Again, they publish this in the annual volumes The Best 168 Medical Schools. It is not a ranking, just a bucket. Personally, I think this genre should have stopped with Susan Berman’s The Underground Guide to the College of Your Choice.

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